Tissue apposition clip application methods

ABSTRACT

Surgical methods for closing a gastrotomy. The surgical method for closing an opening in an organ wall comprises positioning a distal end portion of a steerable overtube adjacent a portion of the organ wall through which the opening extends. The surgical method further comprises inserting a flexible clip magazine into the steerable overtube. The surgical method comprises grasping tissue through which the opening extends and drawing a portion of the grasped tissue into a clamping position between upper and lower clip arms of a distal-most tissue apposition clip supported within a distal end of the clip magazine. The surgical method further comprises advancing the distal-most tissue apposition clip onto the portion of grasped tissue.

This application is a divisional of U.S. patent application Ser. No. 12/172,766, entitled TISSUE APPOSITION CLIP APPLICATION DEVICES AND METHODS, filed on Jul. 14, 2008, which is incorporated herein by reference in its entirety.

FIELD OF THE INVENTION

The present invention relates, in general, to surgical devices and methods of use and, more particularly, to devices and methods for closing a hole or defect in a wall of tissue such as the wall of an organ.

BACKGROUND OF THE INVENTION

Access to the abdominal cavity may, from time to time, be required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Such “open” procedures which require incisions to be made in the abdomen are not particularly well-suited for patients that may have extensive abdominal scarring from previous procedures, those persons who are morbidly obese, those individuals with abdominal wall infection, and those patients with diminished abdominal wall integrity, such as patients with burns and skin grafting. Other patients simply do not want to have a scar if it can be avoided.

Minimally invasive procedures are desirable because such procedures can reduce pain and provide relatively quick recovery times as compared with conventional open medical procedures. Many minimally invasive procedures are performed with a flexible or rigid endoscope (including without limitation laparoscopes). Such procedures permit a physician to position, manipulate, and view medical instruments and accessories inside the patient through a small access opening in the patient's body. Laparoscopy is a term used to describe such an “endosurgical” approach using an endoscope (often a rigid laparoscope). In this type of procedure, accessory devices are often inserted into a patient through trocars placed through the body wall. The trocar must pass through several layers of overlapping tissue/muscle before reaching the abdominal or peritoneal cavity. One of the most significant problems associated with such surgical procedures is the need to provide a secure closure of the peritoneal access site that is required for endoscope passage and, for example, specimen removal. Prior methods required the surgeon to close each of the muscle layers after the procedure is completed.

Still less invasive treatments include those that are performed through insertion of an endoscope through a natural body orifice to a treatment region such as, but not limited to within the peritoneal cavity. Many of these procedures employ the use of a flexible endoscope during the procedure. Flexible endoscopes often have a flexible, steerable articulating section near the distal end that can be controlled by the user by utilizing controls at the proximal end. Minimally invasive therapeutic procedures to treat diseased tissue by introducing medical instruments to a tissue treatment region through a natural opening of the patient are known as Natural Orifice Translumenal Endoscopic Surgery (NOTES)™. Examples of this approach include, but are not limited to, cystoscopy, hysteroscopy, esophagogastroduodenoscopy, and colonoscopy. However, those procedures that involve forming a hole or passage through tissue such as, but not limited to, the stomach, the colon, the vaginal wall, esophagus, etc. still face the challenges associated with securely closing that hole or passage upon completion of the procedure.

Consequently a need exists for devices and methods that can be employed through a patient's natural orifice for closing a passage, hole, defect, incision, etc. made or otherwise ocurring through a wall of tissue such as, for example, the stomach wall, as well as those passages or holes occurring or extending through other tisssues, organs, etc.

The foregoing discussion is intended only to illustrate some of the shortcomings present in the field of the invention at the time, and should not be taken as a disavowal of claim scope.

SUMMARY

In one aspect of the invention, there is provided a clip application device that may include an elongate clip magazine that has an axial clip passage therein for receiving a plurality of tissue apposition clips therein. A pair of grasper lumens may be provided in the elongate clip magazine for accommodating grasper devices therethrough to manipulate tissue adjacent to a distal end of the elongate clip magazine. The device may further include an advancement member for applying an advancement motion to the tissue apposition clips in the axial passage to cause the tissue apposition clips to move out of the axial clip passage in seriatum.

In another general aspect of various embodiments of the present invention, there is provided an adapter for installing a tissue apposition clip that has upper and lower clip arms onto tissue. In various embodiments, the adapter may comprise a body portion that is couplable to a distal end of an endoscope and is configured to releasably retain a tissue apposition clip thereon such that the upper and lower clip arms are retained in an open position to enable tissue to be drawn therebetween and thereafter be released onto the tissue upon application of an advancement force to the tissue apposition clip.

In still another general aspect of various embodiments of the present invention, there is provided a surgical method for closing an opening in a tissue wall. The method may include positioning a tissue apposition clip adjacent a distal end of an endoscope and then positioning the tissue apposition clip adjacent the opening. The method may also include grasping tissue through which the opening extends and drawing a portion of the grasped tissue into a clamping position between upper and lower clip arms of the tissue apposition clip. The method may also include advancing the tissue apposition clip onto the portion of grasped tissue.

Another general aspect of various embodiments of the present invention comprises a surgical method for closing an opening in a portion of an organ wall. The method may include the actions of positioning a tissue apposition clip adjacent a distal end of an endoscope and positioning the tissue apposition clip adjacent the opening. The method may further comprise grasping the portion of the organ wall through which the opening extends and drawing the grasped portion of the organ wall into a clamping position between upper and lower clip arms of the tissue apposition clip. In addition, the method may further comprise advancing the tissue apposition clip onto the grasped portion of the organ wall and applying at least one tissue anchor to the grasped portion or organ wall clamped within the tissue apposition clip.

In another general aspect of various embodiments of the present invention, there is a provided a surgical method for closing an opening in a tissue wall. The method may include positioning a distal end portion of a steerable overtube adjacent a portion of the opening. The method may further include inserting a flexible clip magazine into the steerable overtube, the flexible clip magazine supporting a plurality of tissue apposition clips therein such that the upper and lower clip arms thereof are supported in a spaced open position relative to each other. The flexible clip magazine may have a distal end portion received within said end of the steerable overtube such that the tissue apposition clips supported therein may be selectively discharged out through the distal end of the steerable overtube. The method may also include grasping tissue through which the opening extends and drawing a portion of the grasped tissue into a clamping position between upper and lower clip arms of a distal-most one of the tissue apposition clips supported within the distal end of the clip magazine. The method may also include advancing the distal-most tissue apposition clip onto the portion of grasped tissue.

BRIEF DESCRIPTION OF THE FIGURES

The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the invention, and, together with the general description of the invention given above, and the detailed description of the embodiments given below, serve to explain various principles of the present invention.

FIG. 1 is a perspective view of a tissue apposition clip embodiment of the present invention;

FIG. 2 is diagrammatic view of use of a clip application device embodiment of the present invention inserted through a natural orifice (mouth) of a patient;

FIG. 3 is a perspective view of portion of a clip application device of the present invention;

FIG. 4 is another perspective view of a portion of the clip application device of the present invention with graspers extending out of the distal end thereof;

FIG. 5 is an end view of a clip magazine embodiment of the present invention;

FIG. 6 is a cross-sectional view of the clip application device of FIG. 4 taken along line 6-6 in FIG. 4;

FIG. 7 is a side view of a grasper embodiment;

FIG. 8 is another cross-sectional view of the clip application device embodiment of FIG. 6 with one of the graspers thereof gripping tissue;

FIG. 9 is a partial side view of the clip application device of FIG.8;

FIG. 10 is a partial perspective view of a portion of the clip applier applying a clip to tissue;

FIG. 11 is a perspective view of another clip application device coupled to an endoscope;

FIG. 12 is a diagrammatic view of use of another clip application device embodiment of the present invention inserted through a natural orifice (mouth) of a patient;

FIG. 13 is a perspective view of an endoscope with which a clip adapter embodiment of the present invention may be used;

FIG. 14 is a perspective view of a clip adapter embodiment of the present invention;

FIG. 15 is an end view of the clip adapter embodiment of the FIG. 14;

FIG. 16 is a top perspective view of another a tissue apposition clip embodiment of the present invention;

FIG. 17 is a side perspective view of the tissue apposition clip of FIG. 16;

FIG. 18 is a perspective view of a clip dispenser adapter embodiment on an endoscope;

FIG. 19 is an end view of the clip dispenser adapter embodiment and endoscope of FIG. 18 with a tissue apposition clip installed therein;

FIG. 20 is a side perspective view of the clip dispenser adapter embodiment of FIG. 19 with a grasper protruding out through the distal end thereof to grasp tissue;

FIG. 21 is another perspective view of the clip dispenser adapter embodiment of FIG. 20 illustrating the grasper pulling tissue in between the clip arms of a clip installed therein;

FIG. 22 is a partial cross-sectional view of yet another embodiment of a clip dispenser adapter embodiment of the present invention attached to the distal end of an endoscope;

FIG. 23 is a partial cross-sectional end view of the clip dispenser adapter embodiment of FIG. 22;

FIG. 24 is a partial cross-sectional view of yet another embodiment of a clip dispenser adapter embodiment of the present invention attached to the distal end of an endoscope; and

FIG. 25 is a side view of a clip and clip dispenser embodiment of the present invention being employed with a tissue anchor applier.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the structure, function, manufacture, and use of the devices and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those of ordinary skill in the art will understand that the devices and methods specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments and that the scope of the various embodiments of the present invention is defined solely by the claims. The features illustrated or described in connection with one exemplary embodiment may be combined with the features of other embodiments. Such modifications and variations are intended to be included within the scope of the present invention.

It will be appreciated that the terms “proximal” and “distal” are used herein with reference to a clinician manipulating an end of the instrument 100 that protrudes out of the natural orifice. The term “proximal” referring to the portion closest to the clinician and the term “distal” referring to the portion located away from the clinician. It will be further appreciated that, for convenience and clarity, spatial terms such as “vertical”, “horizontal”, “up” and “down” may be used herein with respect to the drawings. However, surgical instruments are used in many orientations and positions, and these terms are not intended to be limiting and/or absolute.

The present invention generally relates to devices and methods that may be used in connection with the application of tissue apposition clips for closing an opening, hole, passageway, defect, etc. extending through or occurring in a tissue wall. One example of such an opening is known as a “gastrotomy” which comprises an opening formed to gain access to the peritoneal cavity. However, as the present Detailed Description proceeds, it will become readily apparent that the various devices and methods disclosed herein may be successfully employed to apply clips to close various openings, passageways, defects, etc. in a variety of different types of tissue walls, organs, etc. without departing from the spirit and scope of the present invention. “as used herein, the term “tissue wall” is intended to at least encompass all tissues and organs within the human body or animals and includes, but is not limited to, tissue forming the abdominal wall, the stomach, the vaginal walls, the esophagus, the colon, etc. Accordingly, the various devices and methods of the present invention and their respective equivalent structures and methods should not be limited by the nature of the opening to be closed or the particular nature of the tissue through which the openings extend. Furthermore, those of ordinary skill in the art will further appreciate that the devices and methods of the various embodiments of the present invention may also be successfully employed in connection with the application of clips in open or other laparoscopic surgical procedures.

FIG. 1 depicts one embodiment of a tissue apposition clip 20 of the present invention that may be employed to clip a portion of a tissue wall such as, for example, the stomach wall or other tissue as will be discussed in further detail below. In various embodiments, the clips 20 may be fabricated from, for example, stainless steel, Nitinol, titanium or other deformable materials that are implantable within the body and are compatible with that type of environment. As can be seen in FIG. 1, a tissue apposition clip 20 may have a base portion 22 that separates an upper clip arm 24 and a lower clip arm 25 that extend from the base in general confronting relationship to each other. The distal end portions 26 of each clip arm 24, 25 are generally biased towards each other in a “clamping position” or orientation. Each distal end portion 26 may also be formed with two laterally extending protrusions 28, the purpose of which will be discussed below. While the clip 20 depicted in FIG. 1 comprises a preferred tissue apposition clip configuration, other tissue apposition clip configurations could also be employed with the clip application device 100 described below.

In various embodiments, a clip application device 100 of various embodiments of the present invention may be used in connection with a steerable overtube 200. Those of ordinary skill in the art will appreciate that the clip application device 100 may be used in connection with a variety of different steerable overtube arrangements. For example, the steerable overtube 200 may comprise a steerable overtube of the type disclosed in U.S. patent application Ser. No. 11/981,134, filed Oct. 31, 2007, entitled “Endoscopic Overtubes” to Gregory J. Bakos et al., the disclosure of which is herein incorporated by reference in its entirety. Still other overtubes may be employed such as those disclosed in U.S. Pat. No. 5,325,845 to Adair, the disclosure of which is herein incorporated by reference in its entirety. In other embodiments, a steerable overtube of the various types disclosed in commonly owned U.S. patent application Ser. No. 12/172,782, Entitled “Endoscopic Translumenal Articulatable Steerable Overtube” to Gregory J. Bakos et al., filed on even date herewith, now U.S. Pat. No. 8,262,563, and which is hereby incorporated by reference in its entirety, may be successfully employed. In other embodiments, a non-steerable overtube could conceivably be employed, depending upon the application.

As can be seen in FIG. 2, one version of the steerable overtube 200 may interface with an actuator 220 that is used to articulate the distal end portion 222 of the overtube 200. The steerable overtube 200 has a central lumen 202 through which various endoscopic surgical tool and instruments may pass. See FIGS. 3 and 4. The actuator 220 may be used to selectively apply tension to cables or tension members 224 that extend through the wall 226 of the overtube 200 to draw the distal end portion 222 thereof in a desired direction.

Although, as discussed above, the various embodiments of the present invention may be successfully employed to apply clips to and/or close a hole, passageway, defect, etc. in a variety of different tissue walls and organs, one example in which the clip application 100 has particular utility is the closure of a gastrotomy created through the abdominal wall to gain access to the peritoneal cavity. FIG. 2 illustrates one method of deploying an embodiment of the clip application device 100 of the present invention through a natural orifice to close a gastrotomy. As shown in FIG. 2, the steerable overtube 200 may be inserted through the mouth 10 and esophagus 12 into the stomach 14, for example, to enable the surgeon to create a gastrotomy through a portion of the stomach wall. The gastrotomy may be accomplished utilizing various surgical instruments that are operated through the overtube. Once the gastrotomy has been created and the other surgical procedures have been completed, the surgical tools that have been employed up to this point may be removed from the overtube 200 and a clip application device 100 of the present invention may be inserted through the overtube 200 and into the stomach 14 as shown.

FIGS. 3-6 and 8-10 illustrate one embodiment of the clip application device 100 of the present invention. As can be seen in those Figures, the clip application device 100 may include an elongated clip magazine 110 that is sized to extend through the central lumen 202 in the steerable overtube 200. In various embodiments, the clip magazine 110 may be extruded or otherwise formed from polyurethane, silicone, etc. such that the clip magazine 110 may flex or otherwise conform to the steerable overtube 200. The clip magazine 110 may be formed with a centrally disposed axial clip passage 112 that is shaped to movably accommodate at least one and preferably a series, of clips 20 as illustrated in FIG. 6. As can be seen in FIG. 5, the axial clip passage 112 may have a central passage portion 114 and four leg passage segments 116 that protrude laterally from the central passage portion to accommodate the clip arms of the clips 20. As can be seen in FIG. 6, the leg passage segments 116 may serve to support the upper clip arm 24 and the lower clip arm 25 in a spaced open position relative to each other to enable the clip 20 to be installed over tissue as will be discussed in further detail below.

The clip magazine 110 may further have a channel 120 formed therein for operably supporting a conventional endoscopic video camera 130 that communicates with a video display unit 132 that can be viewed by the surgeon during the operation. See FIG. 2. In addition, an advancement channel 140 may be provided in the clip magazine 110 for accommodating various mechanisms for serially advancing the clips 20 out of the distal end of the clip magazine 110.

Also in various embodiments, the clip magazine 110 may be provided with at least one and preferably two lumens 150 for operably accommodating graspers 300. A variety of different known graspers may be employed without departing from the spirit and scope of the present invention. In general, a grasper 300 may include a pair of opposed jaws 302 a, 302 b that are operably located at a distal end 312 of an elongate shaft 310. The proximal end of elongate shaft 310 may be coupled to a handle assembly 320 at collar 322. The handle assembly 320 may further include a fixed handle 324 that is pivotally engaged at point 326 to a moving handle 328. Handles 324, 328 may have grasping loops 330, 332 attached thereto for the convenient insertion of fingers or a thumb therein. The handle assembly 320 depicted in FIG. 7 includes a spring clip 334 and ratchet 336 as two means of providing bias to handles 330, 332 such that jaws 302 a, 302 b are urged in a closed position. Though both are pictured here together (for convenience), usually one or the other is used as means to bias jaws shut. The grasper 300 may further have an adjustable knob 340 which causes shaft 310 and therefore jaws 302 a, 302 b to rotate with respect to fixed handle 330. The jaws 302 a, 302 b may be opened and closed by manipulating the handles 324, 328. A variety of different graspers and grasper jaw configurations are known and may successfully employed in connection with various embodiments of the present invention. Accordingly, the protections afforded to the various embodiments of the subject invention and their equivalent structures should not be limited to the specific grasper configuration depicted in FIG. 7.

To use the device 100, the graspers 300 are inserted into their respective lumens 150 in the clip magazine 110 such that the jaws 302 a, 302 b protrude out through the distal end of the clip magazine 110 as shown in FIG. 5. At least one, and preferably a plurality of, clips 20 are inserted in seriatum into the axial clip passage 112 of the clip magazine 110 and may be advanced therein in the distal direction “DD” by an advancement member 350 that may be inserted into the advancement channel 140 in the clip magazine 110. See FIG. 6. While a variety of different clip advancement mechanisms could be used, the clip advancement member 350 may have a distal end 352 that has a notched portion 354 therein for engaging the proximal-most clip 20 to apply a pushing force thereto in the distal direction “DD”.

When the surgeon desires to apply the clips 20 to the gastrotomy site, the distal end of the clip application device 100 is inserted in through the patient's mouth 10 or other natural orifice such that the graspers 300 may be extended out of the distal end of the clip magazine 110 to grasp the tissue “T” as shown in FIGS. 8-10. Once the tissue “T” has been acquired by the graspers 300 (as observed by the surgeon by means of the camera 130), the surgeon may then pull the grasped tissue proximally between the spaced upper clip arm 24 and lower clip arm 25 of the distal-most clip 20. The surgeon may also begin to apply an advancement force to the proximal-most clip 20 by inserting the advancement member 350 into the advancement channel 140. The application of such advancement force to the proximal-most clip 20 causes the entire series of clips 20 to move proximally in the clip magazine 110 until the distal-most clip 20 is advanced out of the distal end of the clip magazine 110. As can be seen in FIG. 10, the laterally extending protrusions 28 enable the clip 20 to ride up the elongate shaft 310 and the jaws 302 a, 302 b of the graspers 300 to retain the upper and lower clip arms 24, 25 in the spaced open position. The clip 20 continues to be advanced until it engages the tissue “T” and disengages the ends of the grasper jaws 302 a, 302 b. At that point, the clip 20 is holding the tissue folds together and additional clips 20 may be applied in a similar manner or the device 100 may be withdrawn from the patient.

Those of ordinary skill in the art will understand that, although intended to be permanent, these clips 20 may also be designed to slough off intentionally from the clipped tissue to enable the clips to be passed naturally. Although not intended, it is also possible that the clips may come loose from the clipped tissue. In either case, however, it may be desirable for the clips 20 to be sized to enable the clip to pass naturally from the patient without causing harm to the patient. For example, the clips 20 may have smooth rounded edges without significant catch points that could hinder safe passage of the clips 20 from the body.

FIGS. 11-15 illustrate a clip dispensing adapter 400 that may be used with a conventional endoscope 500. As can be seen in FIG. 12, the endoscope 500 may be passed through the steerable overtube 200 and otherwise guided thereby to the site 18 of the opening in the stomach 14. One form of endoscope 500 that may be employed is illustrated in FIG. 13. As can be seen in that Figure, the endoscope 500 may have an elongate, relatively flexible body 502 that has a working channel or lumen 504 extending therethrough. In addition, the endoscope body 502 may have two or more channels 506 that operably support light bundles 508 therein as well as a camera channel 510 for operably accommodating a video camera 130 therein.

On embodiment of a clip dispensing adapter 400 is depicted in further detail in FIGS. 15 and 16. As can be seen in those Figures, the clip dispensing adapter 400 has a body portion 402 that is sized to fit over the distal end 520 of the endoscope 500. In various embodiments, the body portion 402 has an endoscope-receiving cavity 404 therein that may have an inner diameter that is sized relative to the outer diameter of the distal end 520 of the endoscope 500 such that a frictional fit is established therebetween when the adapter 400 is installed onto the distal end 520. See FIG. 15. For example, in such embodiment, the adapter may be fabricated from, for example, stainless steel, polycarbonate, aluminum, etc. In other embodiments, the adapter 400 may be affixed to the distal end 520 of the endoscope 500 by an appropriate adhesive. In still other embodiments, the adapter 400 may be fabricated from a somewhat elastic material such as, for example, silicone, polyurethane, etc. to enable the adapter 400 to be slid over the distal end 520 of the endoscope 500 and retained thereon. In yet other embodiments, the adapter 400 and the distal end 520 of the endoscope 500 may be configured with threads, bayonet-type connections, ratchet connections, etc. to enable the adapter 400 to be removed from the endoscope 500 if so desired. In other embodiments, the adapter 400 may be permanently affixed or otherwise integrally formed into the distal end 520 of the endoscope 500.

As can be seen in FIGS. 14 and 15, the adapter 400 may further include an upper support arm 410 and a lower support arm 420 that protrude outward from the distal end of the body portion 402. The support arms 410, 420 are spaced from each other to receive a tissue apposition clip 600 therebetween. One example of a tissue apposition clip 600 that may be employed is depicted in FIGS. 16 and 17. In various embodiments, the clip 600 may be fabricated from, for example, stainless steel, Nitinol, titanium, hard plastic, etc. and have a base portion 602 that separates an upper clip arm 610 and a lower clip arm 620 that extend from the base in general confronting relationship to each other. The distal end portion 612 of the upper clip arm 610 and the distal end 622 of the lower clip arm 620 are generally biased towards each other in a “clamping orientation”. The distal end 612 may have a folded end portion 614 and the distal end 622 may have a folded end portion 624. The end portions 614 and 624 help to facilitate installation of the clip 600 as it is advanced over folded tissue. In various embodiments, the upper clip arm 610 may have an upper opening 616 therein and an upper slot 618 that extends from the upper opening 616 through the distal end portion 612. Similarly, the lower clip arm 620 has a lower opening 626 and a lower slot 628 extending from the lower opening 626.

FIGS. 18-21 illustrate use of the tissue apposition clip 600 with the adapter 400. For example, as can be seen in FIG. 18, the tissue apposition clip 600 may be positioned between the upper support arm 410 and the lower support arm 420. Upper support arm 410 may have a downwardly extending post 414 that has retainer lug 416 formed thereon that is sized to be received in the upper opening 616 in the upper clip arm 610. Similarly, the lower support arm 420 may have an upwardly extending post 424 that has a retainer lug 426 thereon that is sized to be received in the lower opening 626 in the lower clip arm 620. Thus, to install the tissue apposition clip 600 onto the adapter 400, the tissue apposition clip 600 is oriented between the upper support arm 410 and the lower support arm 420 such that the upper retainer lug 414 extends into the opening 616 and the lower retainer lug 424 extends into the opening 626. The tissue apposition clip 600 is then moved distally such that the post 414 is received in the upper slot 618 and the lower post 424 is received in the lower slot 628 of the clip 600 in the “open” position shown in FIG. 18.

As can be seen in FIGS. 18-21, the base portion 602 of the clip 600 may have a hole 604 therethrough that is aligned with a working channel 504 in the endoscope 500 when the clip 600 is installed onto the adapter 400. This alignment of hole 604 with the working channel 504 enables a grasper 300 to be inserted therethrough to grasp the tissue “T” as shown in FIGS. 20 and 21. Once the surgeon has grasped the target tissue “T” with the grasper 300 in the manner described above and as illustrated in FIG. 20, the surgeon can then pull the grasper 300 and tissue “T” proximally into the open tissue apposition clip 600 as shown in FIG. 21. While the surgeon is pulling the grasper 300 and tissue “T” proximally, the tissue apposition clip 600 may be pushed onto the tissue by advancing an advancement member (rod, bar, other surgical instrument, etc.) through the working channel 505 to contact the clip base 602 and push it distally onto the tissue “T”. When the tissue apposition clip 600 is pushed distally, the lugs 416, 426 will enter the holes 616, 626, respectively in the tissue apposition clip to enable the tissue apposition clip 600 to disengage from the adapter 400 and remain on the tissue “T” as the grasper 300 is withdrawn through the hole 604 and working channel 504.

FIGS. 22 and 23 illustrate another clip dispensing adapter 700 that may be effectively used in connection with the tissue apposition clips 600 described above. As can be seen in those Figures, the clip dispensing adapter 700 has a body portion 702 that is sized to fit over the distal end 520 of the endoscope 500. In various embodiments, the body portion 702 may have an endoscope-receiving cavity 704 therein that may have an inner diameter that is sized relative to the outer diameter of the distal end 520 of the endoscope 500 such that a frictional fit is established therebetween when the adapter 400 is installed onto the distal end 520. For example, in such embodiment, the adapter may be fabricated from stainless steel, aluminum, hard plastic, etc. In other embodiments, the adapter 700 may be affixed to the distal end 520 of the endoscope 500 by an appropriate adhesive. In still other embodiments, the adapter 700 may be fabricated from a somewhat elastic material such as, for example, silicone, polyurethane, elastomer, etc. to enable the adapter 700 to be slid over the distal end 520 of the endoscope 500 and retained thereon. In yet other embodiments, the adapter 700 and the distal end 520 of the endoscope 500 may be configured with threads, bayonet-type connections, ratchet connections, etc. to enable the adapter 700 to be removed from the endoscope 500 if so desired. In other embodiments, the adapter 700 may be permanently affixed or otherwise integrally formed into the distal end 520 of the endoscope 500.

As can be seen in FIGS. 22 and 23, the adapter 700 may further include an upper support arm 710 and a lower support arm 720 that protrude outward from the distal end of the body portion 702. The support arms 710, 720 are spaced from each other to receive a tissue apposition clip 600 therebetween. Upper support arm 410 has a downwardly extending movable post 714 that has retainer lug 716 formed thereon that is sized to be received in the upper opening 616 in the upper clip arm 610. As can be seen in FIGS. 22 and 23, the movable post 714 is movably supported within a slot 713 in the upper support arm 710. In various embodiments, the movable post 714 may have laterally protruding fins 718 that are received in corresponding slots 717 in the upper support arm 710 such that the movable support post 714 can move in the proximal direction “PD” and the distal direction “DD”. The movable support arm 714 is biased into a retention position shown in FIG. 23 by an upper biasing member 719. Similarly, the lower support arm 720 has an upwardly movable post 724 that has a retainer lug 726 thereon that is sized to be received in the lower opening 626 in the lower clip arm 620. As can be seen in FIGS. 23 and 24, the movable post 724 is movably supported within a slot 723 in the lower support arm 720. In various embodiments, the movable post 724 may have laterally protruding fins 728 that are received in corresponding slots 727 in the lower support arm 720 such that the movable support post 724 can move in the proximal direction “PD” and the distal direction “DD”. The movable support arm 724 is biased into a retention position shown in FIG. 23 by a lower biasing member 729.

As can also be seen in FIG. 22, an upper retraction cable 740 extends through a passage 742 in the adapter 700 and is affixed to the upper movable support post 714 and a lower retraction cable 750 extends through a passage 752 in the adapter 700 and is affixed to the lower movable support post 724. The upper and lower retraction cables 740, 750 extend through corresponding passages in a flexible tube 800 that extends over the endoscope 500. In various embodiments, the tube 800 may include a helical wound coil of material that can flex with the endoscope 500 and is substantially coextensive therewith. For example, the flexible tube 800 may be fabricated from stainless steel wire. The various coils 802 of the flexible tube may be provided with corresponding holes 804 through which the retraction cables 740, 750 extend. The distal end 810 of the flexible tube 800 may extend into a retention cavity 760 formed in the proximal end of the adapter body 702 and be attached thereto, by pins, screws, adhesive, etc. The flexible tube 800 serves to guide the refraction cables 740, 750 along the endoscope 500 and out through the patient's mouth or other natural orifice. Pulling on the retraction cable 740 in the proximal direction “PD, causes the upper movable post 714 to move in the proximal direction. Likewise, pulling on the retraction cable 750 in the proximal direction “PD” causes the lower movable post 724 to move in the proximal direction. In alternative embodiments, each cable 740, 750 could extend through its own dedicated flexible coil pipe 741, 751, respectively, which would extend alongside of the endoscope. See FIG. 24.

To install the clip 600 onto the adapter 700, the clip 600 is oriented between the upper support arm 710 and the lower support arm 720. Once positioned in the adapter 700, the surgeon may then apply retraction forces to the retraction cables 740, 750 in the proximal direction such that the upper retainer lug 716 extends into the opening 616 and the lower retainer lug 726 extends into the opening 626 in the clip 600. The surgeon may then release the retraction cables 740, 750 and the upper biasing member 719 biases the upper movable post 714 into the retention position and the lower biasing member 729 biases the lower movable post 724 into the retention position to retain the clip 600 in position between the upper and lower support arms 710, 720. The surgeon may then insert a grasper (not shown) through the working channel in the endoscope 500 and through the clip 600 to grasp the tissue in the manner described above and then pull the tissue into a position between the upper and lower clip arms 610, 620. The surgeon may then pull the retraction cables to enable the upper and lower retainer lugs 716, 726 to extend into the respective openings 616 and 626 in the clip 600 to thereby enable the clip to be pushed into the distal direction “DD” by a discharge member, bar, surgical tool inserted through the discharge lumen in the endoscope. Again the surgeon releases the grasper from the tissue and retrieves the grasper from the working channel. The clip 600 remains installed on the tissue and the endoscope may then be withdrawn from the patient to enable another clip 600 to be installed on the adapter if addition clips are required and the process then be repeated again.

Another feature of clip 600 is the ability to facilitate the installation of tissue anchors or sutures to the clipped tissue by passing a tissue anchor applier 900 through the endoscope 500 and through the hole 604 in the clip 600 as shown in FIG. 25. A variety of such tissue anchor appliers are known. For example, tissue anchor applier 900 may comprise any of the tissue anchor applying devices disclosed in any of the following cited documents, the disclosures of which are each herein incorporated by reference in their respective entireties: (i) U.S. Patent Application Publication No. US2008/0103527 A1 to David T. Martin et al., entitled “Flexible Endoscopic Suture Anchor Applier”, Ser. No. 11/553,489, filed Oct. 27, 2006. (ii) U.S. Patent Application Publication No. US 2007/0270907 A1, to Michael J. Stokes et al., entitled “Suture Locking Device”, Ser. No. 11/437,440, filed May 19, 2006, (iii) U.S. Patent Application Publication No. US 2007/0270889 A1 to Sean P. Conlon et al., entitled “Combination Knotting Element and Suture Anchor Applicator”, Ser. No. 11/437,864, filed May 19, 2006, and (iv) pending co-owned U.S. patent application Ser. No. 11/796,035 to David Stefanchik et al., entitled “Surgical Suturing Apparatus”, filed Apr. 26, 2007. As can be seen in FIG. 25, the needle portion 902 of the tissue anchor applier 900 is introduced through the endoscope 500 to enable it to pierce through the tissue “T” on both sides of the opening. For example, when the opening comprises a gastrotomy, the needle 902 of the tissue anchor applier 900 may be able to pierce the tissue “T” on both sides of the gastrotomy while remaining in the stomach. This may be a significant safety advantage when compared to use of prior closure systems. For example, when employing prior closure systems and methods, a mucosa-mucosa apposition is created. When employing the clip 600 of the present invention, a serosa-to-serosa apposition is created which may result in a more secure/permanent healing of the gastrotomy.

As can be readily appreciated from the foregoing, the various embodiments of the present invention described above represent a vast improvement over prior devices and methods used to apply tissue apposition clips for closing gastrotomies. The unique and novel features of the various embodiments of the present invention enable the operation to be performed through a natural orifice in the patient and thereby avoid several disadvantages associated with other conventional surgical methods and procedures that require incisions to be made into the abdomen. The present invention may comprise a device that contains several clips that may be serial advanced onto tissue that is grasped and manipulated using conventional tissue grasping devices. Other embodiments may comprise a clip dispensing adapter that may be applied to a distal end of a conventional endoscope and, if desired, supplied and/or sold separately from the endoscope. Such adapters may be pressed onto, threaded onto or otherwise temporarily attached to the distal end of the endoscope to complete the above-described procedure and thereafter removed from the endoscope and discarded or reprocessed for future use. Other embodiments of the present invention contemplate permanent attachment of the adapter to the distal end of the endoscope and still other embodiments envision that the adapter may be integrally formed on the distal end of the endoscope.

While several embodiments of the invention have been described, it should be apparent, however, that various modifications, alterations and adaptations to those embodiments may occur to persons skilled in the art with the attainment of some or all of the advantages of the invention. For example, according to various embodiments, a single component may be replaced by multiple components, and multiple components may be replaced by a single component, to perform a given function or functions. This application is therefore intended to cover all such modifications, alterations and adaptations without departing from the scope and spirit of the disclosed invention as defined by the appended claims.

The devices disclosed herein can be designed to be disposed of after a single use, or they can be designed to be used multiple times. In either case, however, the device can be reconditioned for reuse after at least one use. Reconditioning can include an combination of the steps of disassembly of the device, followed by cleaning or replacement of particular pieces, and subsequent reassembly. In particular, the device can be disassembled, and any number of particular pieces or parts of the device can be selectively replaced or removed in any combination. Upon cleaning and/or replacement of particular parts, the device can be reassembled for subsequent use either at a reconditioning facility, or by a surgical team immediately prior to a surgical procedure. Those of ordinary skill in the art will appreciate that the reconditioning of a device can utilize a variety of different techniques for disassembly, cleaning/replacement, and reassembly. Use of such techniques, and the resulting reconditioned device, are all within the scope of the present application.

Preferably, the inventions described herein will be processed before surgery. First a new or used endoscope is obtained and, if necessary, cleaned. The endoscope can then be sterilized. In one sterilization technique, the endoscope is placed in a closed and sealed container, such as a plastic or TYVEK® bag. The container and endoscope are then placed in a field of radiation that can penetrate the container, such as gamma radiation, x-rays, or higher energy electrons. The radiation kills bacteria on the endoscope and in the container. The sterilized endoscope can then be stored in the sterile container. The sealed container keeps the endoscope sterile until it is opened in the medical facility.

Any patent, publication, application or other disclosure material, in whole or in part, that is said to be incorporated by reference herein is incorporated herein only to the extent that the incorporated materials does not conflict with existing definitions, statements, or other disclosure material set forth in this disclosure. As such, and to the extent necessary, the disclosure as explicitly set forth herein supersedes any conflicting material incorporated herein by reference. Any material, or portion thereof, that is said to be incorporated by reference herein, but which conflicts with existing definitions, statements, or other disclosure material set forth herein will only be incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material.

The invention which is intended to be protected is not to be construed as limited to the particular embodiments disclosed. The embodiments are therefore to be regarded as illustrative rather than restrictive. Variations and changes may be made by others without departing from the spirit of the present invention. Accordingly, it is expressly intended that all such equivalents, variations and changes which fall within the spirit and scope of the present invention as defined in the claims be embraced thereby. 

What is claimed is:
 1. A surgical method for closing an opening in an organ wall, said surgical method comprising: positioning a distal end portion of a steerable overtube adjacent a portion of the organ wall through which the opening extends; inserting a flexible clip magazine into the steerable overtube, the flexible clip magazine supporting a plurality of tissue apposition clips therein such that upper and lower clip arms thereof are supported in a spaced open position relative to each other, said flexible clip magazine having a distal end portion received within said distal end portion of the steerable overtube such that the tissue apposition clips supported therein may be selectively discharged out through the distal end portion of the steerable overtube; grasping tissue through which the opening extends; drawing a portion of the grasped tissue into a clamping position between upper and lower clip arms of a distal-most one of the tissue apposition clips supported within the distal end portion of the clip magazine; and advancing the distal-most tissue apposition clip onto the portion of grasped tissue.
 2. The surgical method of claim 1 further comprising: repositioning the distal end portion of the steerable overtube adjacent another portion of the opening; grasping other tissue through which the opening extends; drawing a portion of the grasped other tissue into a clamping position between upper and lower clip arms of another distal-most one of the tissue apposition clips supported within the distal end portion of the clip magazine; and advancing the another distal-most tissue apposition clip onto the portion of grasped other tissue.
 3. The surgical method of claim 1 wherein the opening in the organ wall is selected from a group of openings consisting of an opening in a stomach, an opening in a colon, an opening in a vagina, and an opening in an esophagus.
 4. The surgical method of claim 1 further comprising clamping the distal-most one of the tissue apposition clips onto the portion of grasped tissue when the portion of the grasped tissue is drawn into the clamping position between the upper and lower clip arms.
 5. The surgical method of claim 4, wherein clamping the distal-most one of the tissue apposition clips onto the portion of the grasped tissue creates a serosa-to-serosa apposition.
 6. The surgical method of claim 4, wherein grasping tissue through which the opening extends comprises passing a lumen through holes in the tissue apposition clips.
 7. A surgical method for closing an opening in a portion of an organ wall, said surgical method comprising: positioning a tissue apposition clip adjacent a distal end of an endoscope; positioning the tissue apposition clip adjacent the opening; grasping the portion of the organ wall through which the opening extends; drawing the grasped portion of the organ wall into a clamping position between upper and lower clip arms of the tissue apposition clip; advancing the tissue apposition clip onto the grasped portion of the organ wall; and applying at least one tissue anchor to the grasped portion of organ wall within the tissue apposition clip.
 8. The surgical method of claim 7 wherein said positioning the tissue apposition clip adjacent the distal end of the endoscope, comprises: coupling a clip dispensing adapter to the distal end of the endoscope; releasably supporting the tissue apposition clip on the clip dispensing adapter; and movably manipulating the distal end of the endoscope and adapter adjacent to the opening through the portion of organ wall.
 9. The surgical method of claim 8 wherein said positioning the tissue apposition clip adjacent the distal end of the endoscope comprises inserting the distal end of the endoscope and adapter through a natural orifice in a patient and manipulating the distal end of the endoscope and adapter by applying actuation forces thereto from a portion of the endoscope positioned external to the natural orifice.
 10. The surgical method of claim 7 wherein said applying at least one tissue anchor to the grasped portion of organ wall within the tissue apposition clip comprises inserting a tissue anchor applier through a hole in the tissue apposition clip to operably engage the grasped portion of organ wall within the tissue apposition clip.
 11. The surgical method of claim 7 further comprising clamping the tissue apposition clip onto grasped portion of organ when the grasped portion of organ is drawn into the clamping position between the upper and lower clip arms.
 12. The surgical method of claim 11, wherein clamping the tissue apposition clip onto the portion of the grasped tissue creates a serosa-to-serosa apposition.
 13. A surgical method for closing an opening in tissue, said surgical method comprising: positioning a tissue apposition clip adjacent a distal end of an endoscope; positioning the tissue apposition clip adjacent the opening in the tissue; grasping a portion of the tissue through which the opening extends; drawing the portion of the grasped tissue into a position between upper and lower clip arms of the tissue apposition clip; and advancing the tissue apposition clip onto the portion of grasped tissue.
 14. The surgical method of claim 13 further comprising clamping the tissue apposition clip onto the portion of grasped tissue.
 15. The surgical method of claim 14, wherein clamping the tissue apposition clip onto the portion of the grasped tissue creates a serosa-to-serosa apposition.
 16. The surgical method of claim 13 wherein said positioning the tissue apposition clip adjacent the distal end of the endoscope, comprises: coupling a clip dispensing adapter to the distal end of the endoscope; releasably supporting the tissue apposition clip on the clip dispensing adapter; and movably manipulating the distal end of the endoscope and adapter adjacent to the opening.
 17. The surgical method of claim 13 further comprising applying at least one tissue anchor to the portion of grasped tissue within the tissue apposition clip.
 18. The surgical method of claim 17 wherein said applying at least one tissue anchor to the portion of grasped tissue within the tissue apposition clip comprises inserting a tissue anchor applier through a hole in the tissue apposition clip to operably engage the portion of grasped tissue within the tissue apposition clip.
 19. The surgical method of claim 13, wherein grasping the tissue through which the opening extends comprising passing a lumen through holes in the tissue apposition clips to grasp a portion of the tissue.
 20. The surgical method of claim 13 wherein the opening in the tissue comprises an opening in an organ wall. 